Overview
Definition:
Breast-conserving surgery (BCS), also known as lumpectomy, is a surgical procedure that removes only the cancerous tumor from the breast along with a surrounding margin of healthy tissue
This approach aims to preserve as much of the breast as possible while achieving complete tumor removal
The assessment and achievement of clear surgical margins are paramount to reducing the risk of local recurrence.
Epidemiology:
Breast-conserving surgery is the preferred surgical treatment for the majority of early-stage breast cancers, accounting for approximately 60-70% of all breast cancer surgeries in developed countries
The incidence of early-stage breast cancer, which is amenable to BCS, remains significant globally
Demographic factors influencing BCS choice include tumor stage, size, patient preference, and availability of adjuvant radiation therapy.
Clinical Significance:
BCS offers oncological safety comparable to mastectomy for appropriately selected patients, with the significant benefit of preserving breast aesthetics and improving quality of life
Achieving negative margins is critical for the success of BCS, directly impacting local control rates and the need for re-excision or salvage mastectomy
Understanding margin assessment is therefore fundamental for surgical residents preparing for DNB and NEET SS examinations.
Indications
Indications For Bcs:
Suitable for unifocal, non-invasive, or small invasive breast cancers where complete removal with adequate margins is feasible without significant cosmetic deformity
Patient preference for breast preservation and absence of contraindications like multicentric disease, inflammatory breast cancer, or prior radiation to the breast are key factors
Contraindications include large tumors relative to breast size, inability to achieve negative margins, or patient preference for mastectomy.
Margin Requirements:
Current guidelines generally recommend a negative margin of at least 1-2 mm for invasive breast cancer and clear margins for ductal carcinoma in situ (DCIS)
The definition of "clear margin" can vary slightly by pathology, but it generally means no tumor cells at the inked edge of the specimen
Achieving these margins is crucial for local tumor control.
Multidisciplinary Assessment:
The decision for BCS is often made within a multidisciplinary team context, involving surgeons, oncologists, radiologists, and pathologists
Preoperative imaging (mammography, ultrasound, MRI) is essential for tumor localization and assessment of multifocality
Core needle biopsy confirmation of malignancy is a prerequisite.
Procedure Steps
Preoperative Planning:
Accurate tumor localization is essential, often involving wire or radioactive seed localization for non-palpable lesions
Sentinel lymph node biopsy (SLNB) is typically performed concurrently to assess nodal status
Detailed marking of the surgical site and planning for cosmetic outcome, especially in oncoplastic techniques, are important.
Surgical Technique:
An incision is made around the tumor, and the tumor is dissected en bloc with a surrounding margin of normal breast tissue
The specimen is oriented using ink or sutures to help the pathologist assess the margins
Hemostasis is achieved, and the breast tissue is approximated
The wound is closed in layers.
Specimen Handling And Pathology:
The specimen is sent for immediate pathological examination to assess margins
If margins are positive, intraoperative frozen section analysis may be performed to guide further resection
Pathological assessment includes tumor type, grade, size, nodal status, and margin status
Radiotherapy is typically recommended postoperatively for BCS patients.
Margin Assessment And Management
Pathological Evaluation:
The pathologist meticulously examines all surfaces of the excised specimen
The presence or absence of tumor cells at the inked margin is the primary endpoint
Different tumor types (e.g., invasive carcinoma, DCIS, lobular carcinoma) may have specific margin considerations.
Management Of Positive Margins:
Positive margins indicate residual tumor and necessitate further intervention to reduce the risk of local recurrence
Options include re-excision of the positive margin area or proceeding to mastectomy
The extent of re-excision depends on the location and size of the positive margin, and the tumor characteristics.
Intraoperative Margin Assessment:
Techniques like specimen radiography (to identify calcifications) and intraoperative ultrasound can assist in identifying suspicious areas at the time of surgery
Frozen section analysis of margins can be performed, though it has limitations in accuracy for certain tumor types and can delay the procedure.
Postoperative Care And Follow Up
Immediate Postoperative Care:
Wound care, pain management, and monitoring for complications like hematoma or seroma formation are essential
Patients are typically discharged within 24-48 hours
Drain management may be required.
Adjuvant Treatment:
Adjuvant radiation therapy is standard for most BCS patients to reduce local recurrence rates
Systemic adjuvant therapy (chemotherapy, endocrine therapy, targeted therapy) is based on tumor biology (e.g., hormone receptor status, HER2 status, genomic profiling) and nodal status.
Long Term Follow Up:
Regular follow-up appointments with clinical breast examinations, mammography, and potentially other imaging modalities are crucial to monitor for local recurrence, contralateral breast cancer, or distant metastases
The surveillance schedule is typically annual mammography and clinical exams every 6-12 months for the first few years.
Complications
Early Complications:
Hematoma, seroma formation, wound infection, delayed wound healing, cosmetic asymmetry, and anesthesia-related complications
Pain and discomfort are common in the immediate postoperative period.
Late Complications:
Breast asymmetry or deformity, fibrosis, radiation-induced changes in the breast (e.g., skin thickening, telangiectasias), lymphedema (especially if axillary dissection was performed), and local recurrence
Psychological impact and body image concerns can also be significant.
Prevention Strategies:
Meticulous surgical technique, appropriate patient selection, effective hemostasis, judicious use of drains, and adherence to radiotherapy protocols can minimize complications
Oncoplastic techniques can improve cosmetic outcomes
Careful margin assessment prevents positive margins and subsequent re-operations or mastectomy.
Key Points
Exam Focus:
Understanding the indications for BCS, the definition of clear margins (1-2 mm for invasive, clear for DCIS), the management of positive margins (re-excision vs
mastectomy), and the importance of adjuvant radiotherapy
Sentinel lymph node biopsy is an integral part of BCS
DNB/NEET SS questions often focus on decision-making for BCS and margin management.
Clinical Pearls:
Always orient your specimen meticulously for the pathologist
If a margin is positive, discuss the best course of action (re-excision vs
mastectomy) with the multidisciplinary team and the patient
Consider oncoplastic techniques to improve cosmetic outcomes, especially in larger tumors or breasts requiring significant tissue removal.
Common Mistakes:
Inadequate margin assessment, failure to re-excise positive margins appropriately, suboptimal tumor localization leading to missed tumor or unnecessary tissue removal, and underestimation of the importance of adjuvant radiotherapy
Ignoring patient preferences and psychosocial factors is also a common oversight.